How to review your utilization review in 2021

In today’s health care environment, there are so many barriers to success. For critical access hospitals, utilization review is the first (and often the last) line of revenue defense. With strict parameters (< 96 hour stays, high-acuity patients), discerning inpatient versus outpatient status could not be more crucial. Yet critical access and rural hospitals face clear constraints – lean staffing, less technology, limited size – that make utilization without effective “review” a common occurrence.

Despite these barriers, there are steps that critical access and rural hospitals can take to assess where they are in the realm of utilization review and outline a path to where they want to be.
Step 1: Review your UM plan
Your hospital has a utilization management plan as governed by 42 CFR § 482.30: Condition of participation: Utilization review. In this plan, you are required to undertake reviews of your patients for medical necessity, extended stays, and so on. One often overlooked piece is the “tool” required for utilization review – but CMS does not specify any particulars, only that a clinically driven review must be completed. Traditional screening tools frequently fill this need, yet they are often inadequate in preventing a denial or representing a patient clinically. It is important to figure out what works for your organization while complying with the conditions of participation – are the tool, the process, and the data setting you up for success? If not, search for a new solution or support mechanism. UM has a big impact, so it deserves a thorough approach.
Step 2: Review your impact
Historically, utilization review has been time-consuming, manual, subjective, and ineffective. Ask yourself: Are you plagued by medical necessity denials? Are your patients receiving thorough reviews? Are you managing throughput effectively and ensuring all patients receive the right care at the right time in the right status? Are you managing length of stay effectively to maintain the annual average of 96 hours or less?

One or two nurses are often tasked with utilization review at rural facilities – along with a mountain of other responsibilities. “It’s just me,” shares one critical access hospital utilization review nurse. “[I] am doing all the reviews, I am doing all the paperwork.” Her frustration is real: Limited staffing means a lot of weight on an individual’s shoulders to ensure utilization review is top tier while also juggling various hospital demands. If you want to see improvement, compare historical data to benchmarked data to better understand opportunities in financial and operational metrics related to utilization review. A lack of real-time access and activity can be addressed through creative strategies as well as technology.
Step 3: Review your technology
Does your technology just cover utilization review, or is it centered on it? Many individuals responsible for UM at critical access and rural hospitals are wary of the “deep dive” into the electronic medical record, an endless search for data points and clinical validators that piece together a strong and defensible case for inpatient status. This process is painstaking and prolongs the review, making the process less efficient and more subjective (especially if something is missed).

Ask yourself: Does your facility have a way to prioritize and identify cases in the wrong status? If not, is there a process you can put in place to mitigate this or a tool that can do it automatically? Rural hospitals are increasingly looking to tools that leverage analytics and data to empower staff. Efficiency pays dividends in terms of financial gain and staff satisfaction.
Step 4: Review the potential
If you eliminated your main sources of denied claims, what are the financial implications for your facility? If your staff were able to undertake utilization review seamlessly, effectively, and efficiently, how could that bolster your operations and your bottom line? If you could get status right every time while making each case airtight and defensible, what could that do for you? Are you able to access reporting that drives insight? If not, can you outsource or find a way to adapt? If there’s potential for improvement, there’s incentive for change – both operational and financial.

These four steps are the first towards understanding where you can apply foresight. In 2021, an effective utilization review process can help ensure your organization receives adequate and appropriate compensation for the care you provide. It’s time to take stock and take steps to get to that effective process.

NRHA adapted the above piece from XSOLIS Utilization Review Software, a trusted NRHA partner, for publication within the Association’s Rural Health Voices blog

XSOLIS and many more NRHA Parnters will present several of the more than 80 innovative, practical, and cost-saving sessions is at NRHA’s virtual 44th Annual Rural Health Conference, 6th Rural Hospital Innovation Summit, and more May 4-7.